Evaluating essential medicines for treating childhood cancers: availability, price and affordability study in Ghana

According to the World Health Organization (WHO) childhood cancer fact sheet, cancer is the primary cause of mortality in children and adolescents worldwide [1, 2]. Children living in high-income countries (HICs) constitute approximately 10% of the global children population where access to cancer care is optimal [3]. On the contrary, 90% of the global childhood cancers are recorded in low-and-middle-income countries (LMICs), yet, there is limited access to affordable medications in LMICs [4]. Consequently, survival estimates in LMICs are scandalously lower than those in HICs. As earlier indicated by the WHO, children with cancer in LMICs are four time more likely to die of the disease than children from HICs [5]. Reasons cited for this disproportional burden include late diagnosis of the disease, abandonment of treatment due to high cost and lack of specialized care [5].

In Ghana, available data indicate that the average number of new childhood cancers recorded at the two primary referral public hospitals, Korle-Bu Teaching Hospital and Komfo Anokye Teaching Hospital were 124 and 103 cases per year respectively [6, 7]. Studies suggest that the treatment of childhood cancers in LMICs is economically feasible [8, 9]. However, access to cost-effective healthcare, including essential cancer medicines, is a significant challenge [10]. In Ghana, childhood cancers are not integrated into national social programs. Hence, children with cancer do not benefit from health packages and their treatment are not covered under the National Health Insurance Scheme (NHIS) [11]. Thus, their healthcare services, including essential cancer medicines, are paid out-of-pocket. This phenomenon, as suggested by many studies, lead children with symptoms suggestive of cancer and their parents/guardians to seek healthcare from herbalist and sometimes at private and other lower-level health facilities instead of specialist cancer center. This consequently leads to delay in diagnosis and treatment [12, 13]. Therefore, it is essential to evaluate the cost, affordability and availability of childhood cancer medicines in Ghana to understand the caregivers’ burden and also inform policies.

In 2009, the WHO Expert Committee on the selection and use of Essential Medicines discussed the importance of including cancer medicines on the List of Essential Medicines for Children (EMLc) [14]. In 2011, the Expert Committee approved the inclusion of cancer medicines for the treatment of Wilms tumor, acute lymphoblastic leukemia (ALL), and Burkitt lymphoma in the EMLc (Table 1) [14]. The overall aim for the development of EMLc by the Expect Committee aimed to serve as guidance for LMICs to create their country-specific lists to improve the availability, affordability, and accessibility of essential cancer medicines required for the treatment of childhood cancers [10]. It further set a target of 80% availability of essential childhood cancer medicines [10] across the public and private health care sectors.

One of the milestones in achieving the Sustainable Development Goals (SDGs), in particular SDG target 3.4 in LMICs is to reduce premature mortality from childhood cancers through the provision of cost-effective medicines. In September 2018, the WHO announced a new effort- the WHO Global Initiative for Childhood cancer – with the goal of reaching at least a 60% survival rate for children with cancer by 2030 [5]. The aim of this initiative is in two-fold [1]; increase prioritization of childhood cancer through awareness raising at global and national levels and [2] expand the capacity of countries in cancer diagnosis and treatment including availability of medicines and to deliver best practices [5]. The significant barrier to access essential cancer medicines in LMICs is high prices. If as a society, we are going to make positive development towards Target 3.4 to reduce premature mortality from childhood cancers and achieve 60% survival rates in less developed countries such as Ghana, we will have to develop policies that will improve the affordability, availability, and prices of childhood cancer medicines. Measuring and evaluating essential medicines prices are vital activities as these findings will inform the development of such policy and practice guidelines.

The WHO/Health Action International (HAI) has designed a method to determine the price, affordability, and availability of essential medicines [15]. The WHO/HAI method employs the Management Sciences for Health (MSH) international reference prices, which are globally accepted as the reference model, informing realistic procurement prices acquired through global tender prices and non-profit distributors to LMICs [16]. Considering the significance of essential cancer medicine prices and availability in patient access, WHO set a price target of not more than four times the international reference price across the public and private health care sectors [10].

The WHO/HAI method has been used to evaluate availability, price, and affordability of essential medicines in many regions of the world [10] but it has not been used to evaluate essential childhood cancer medicines in Ghana. The Ghana EMLc includes all the cancer medicines approved by the WHO Expert Committee, and it is vital to find out if these cancer medicines are easy-to-access by patients. Thus, the study aimed to access the availability, pricing, and affordability of essential cancer medicines in Ghana using the pediatric oncology unit of a tertiary hospital as the anchor point.

A cross-sectional survey was undertaken using a modified form of the WHO/HAI method [17] to measure the availability, affordability, and price of childhood cancer medicines in the private and public retail pharmacies in the Ashanti region of Ghana. This region has one of the two national pediatric oncology centers for treating childhood cancer. Also, it is the most populated region in the country, with the highest incidence and prevalence rates of childhood cancers [6]. All methods used to generate data for this study were carried out in accordance with relevant guidelines and regulations of the Pharmacy Council of Ghana. Further, formal permissions were obtained from 4 private retail pharmacies and pharmacies of a tertiary health care facility involved in this study prior to the commencement of data collection (RD/CR20/155). For each of the 28 medicines included in the study, availability, and pricing data were collected for innovator brand and lowest price generic brand if available. The innovator brand is the first medicine created containing the exact active ingredient to receive approval for use. Whiles, the generic brand is a medicine created to be similar to an already marketed brand-name medicine in dosage form, strength, safety, route of administration, performance characteristics, quality, and intended use [18]. Ethical clearance for the study was granted by the Committee on Human Research, Publication and Ethics, Kwame Nkrumah University of Science and Technology, Ghana (Ref: CHRPE/AP/467/20).

An assessment was done to explore the viability of the study at the selected sites. This assessment included off-peak periods at the retail pharmacies, duty roaster of pharmacists at the sites, and restocking periods. Trained research assistants visited the selected retail pharmacies, engaged the pharmacists on duty on the survey day, and had them fill a data collection sheet designed by the authors. KBM and ABBM cross-checked the price and physical availability of the survey medicines at the sites.

As far as it is known, this is the first comprehensive analysis of availability, prices, and affordability of paediatric cancer medicines in Ghana. The overall availability of cancer medicines fell below the WHO target for essential cancer medicines of 80% [23, 24]. The mean availability of these medicines was poor at the hospital pharmacies (27%) compared to the private pharmacies (75%). Chemotherapy service is provided at the hospital, so ideally the availability of cancer medicines is expected to be high at the hospital. The unsatisfactory availability of cancer medicines at the hospital pharmacies may indicate insufficient government funding for childhood cancer medicines. This is evidenced by the government 2019 budget to the Ghana Health Service which consisted of 99.8% for employee’s emolument and only 0.2% for services and goods [25]. The Internally Generated Fund (IGF) has been used as the primary source of funding for services and goods in the health sector. Nevertheless, IGF is meant to be spent on clinical services only [25]. This indicates that there are no or little funds provided to pay for medicines at even the basic level of the health system [25]. Simpler studies done in low-middle-income country’s (LMICs) such as Dar es Salaam (Tanzania) and Punjab (Pakistan) also reported poor availability of cancer medicines at public or government hospital pharmacy than the private pharmacy [26, 27]. The study done in Dar es Salaam concluded that government budget allocated for the purchase of cancer medicines was very small compared to the rising cases of both childhood and adult cancers. The Pakistan study also indicated that the government of Pakistan cannot maintain good public healthcare because of financial limitations [28]. Hence, government hospitals mostly experience a shortage of medicine [26].

Other factors contributing to inadequate availability of cancer medicines at the hospital pharmacies may be due to delays in awarding tenders, long lead times, failure to pay suppliers, poor supplier performance, and failure of suppliers to meet demands. Some of these contributing factors have been reported in other LMICs like Kenya and South Africa [29, 30].

The broader availability of cancer medicines at the private pharmacies may be explained by the high productivity and maximization of profit of the private sector, as seen in a market-oriented economy like Ghana.

The availability of five medicines (I.V. Carboplatin 450 mg, I.V. Etoposide 100 mg, I.V. Cyclophosphamide 500 mg, I.V. Doxorubicin 50 mg, and I.V. Granisetron 1 mg) at all survey site may be due its high demand because of its indication in the five common childhood cancers and other various cancers.

Our study highlights little significance in assessing or exploring the availability of innovator brand cancer medicines as shown by other studies [10, 31, 32]. Most innovator brand cancer medicines have lost their patent protection; hence, generic brands are widely available than innovator brands [33], and substitution with a generic brand is widely recognized in the public and private health system. .

The median MPR of all surveyed medicines, both cancer, and non-cancer medicines, were less than four, demonstrating comparatively lower local prices to international reference prices. Most of the generic cancer medicines available in Ghana are imported from India. This is evident in data from TradeMap, which suggests that $282 million value of pharmaceuticals was imported into Ghana in 2018, out of which 65% were from India [34]. This is because India has a large number of generic manufacturers [35‐37] and also has the lowest consumer prices on cancer medicines [38]. Hence, this may explain the low median MPR achieved in the survey.

In Ghana, there are no regulatory or legal provisions controlling the pricing of medicines .The government does not provide an active nationwide medicines price regulation system for retail prices [39]. There is no existence of any legislation that mandates that medicine price information should be publicly available [40]. This may explain why some medicines (oral Methotrexate and I.V. 5-fluororuracil, Prednisolone 5 mg, Alopurinol 100 mg and 300 mg) were more than four times the international reference price. The authors recognize that there may be diverse economic drivers that can determine medicine prices but are not considered in this study.

The affordability of medicine is considered reasonable if the cost of treating a disease course is equal to or less than a day wage of the minimum-paid government employee [41]. Nevertheless, cancer treatment required more than one working day to pay for a day’s treatment, which is considered unaffordable to most patients [26, 27]. The price of the surveyed medicines was comparatively low to international reference prices. However, the cost of chemotherapy treatment for ALL and retinoblastoma was not affordable. Our result is similar to other studies done in LMICs, which reported that cancer medicines are not affordable [26, 27, 42].

Most anti-cancer medicines surveyed were found in the private pharmacy; however, the mean availability across all surveyed pharmacies was below the WHO set target of 80%. The low availability of medicines at the public pharmacies indicates the need for government intervention and strengthening of the existing procurement, supply, and distribution system at the hospital.

The price of surveyed medicines was below the international reference price but unaffordable for the government minimum-paid worker in Ghana. Children with cancer require a reliable supply of affordable cancer medicines. The absence of such a supply of affordable medicines can lead to preventable mortality and morbidity.

A range of policies and technical options are available for the government to ensure that cancer medicines are available and affordable. We recommend some of these options such as improvement in price transparency, health insurance schemes for childhood cancers, subsidies for essential childhood cancer medicines, prioritizing cancer medicines for national EMLc, and importation of cancer medicines by the government.

This work supports the international agenda aimed to improve global childhood cancer outcomes [43] by providing baseline data on access to essential childhood cancer medicines in Ghana.